Name: (as it appears on the card): _______________________________

Address1: _______________________________

Address2: _______________________________

City:_______________________________

State: _______________________________

Zip Code: _______________________________

Email: _______________________________

Telephone number we should call if there is a problem with your card
(Please indicate the best time to reach you) _____________________

Amount you wish charged to your credit card: ______________

Service you are purchasing:($75.00 Quick Writing Analysis, or $75.00 Quick Writing Analysis, plus $25.00 for each additional page over 2 pages)

______________

Card Type: _______________________________

Card # _______________________________

Expiration Date: _______________________________

AVS Code (3-digit number on back of card) ______

My contract and materials are enroute: ________

My contract and materials will be sent: (Date) ______

Signature__________________

Date___________